This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Tuesday, March 04, 2008

The SPIRIT arises

(Email yesterday to the BIDMC Community, formally kicking off this adventure.)

Dear BIDMC,

Today we begin BIDMC SPIRIT across the medical center. Don’t expect flag-waving, speeches or any fanfare like that. This week is about first steps.

Why do we need to do this? Please read the following situations from some of our SPIRIT training sessions over the past few weeks:

The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station.

When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps, hand-addressing the envelopes and dropping them in a US mailbox.

We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday!

I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none.

Think back to your first day of working here: Was it your goal to deal with situations like these? Probably not! But we all acknowledge that it happens every day. No matter where you work at BIDMC, you probably spend a chunk of your time hunting for things, tracking down something or someone you need, and fetching materials. You are well-intentioned, hard-working, creative and industrious. You have found ways to provide excellent patient care or support for patient care in spite of the challenges. Often you create “work-arounds” to simply get your work done. The problem with work-arounds, though, is that underlying systemic problems don’t get fixed. Now, with BIDMC SPIRIT, we aim to fix them.

My hope is to have us improve the quality of the time you spend here so you can focus on the things that matter instead of working around the problems you encounter. We know from other places that this can happen. They key is to empower every single person to call out problems, participate in solutions, and be appreciated for his or her contributions.

I will promise you one thing, though. During the first few weeks of SPIRIT, activities may feel clumsy – and perhaps chaotic. The number of problems called out will certainly exceed the number that can be worked on in real time. Not all of our managers have been formally trained, but we can’t wait for the timing to be perfect. We have to get started. So be please patient with each other – and especially me! -- as we get this going.

You probably have lots of questions. To learn more about how SPIRIT works, please read this Q and A (Note: This linked to the document below.). There are posters and flyers around in four languages so we can make sure that staff who don’t use computers or those for whom English is a second language are involved.

I also ask you to visit the general portal and click on the BIDMC SPIRIT logo some time this week. You’ll find a problem log up-and-running. Real-life, BIDMC problems and solutions from the first SPIRIT trainings are already there for everyone to see and learn from. It’s a great way to see what SPIRIT is.

You will be hearing much, much more about BIDMC SPIRIT in the coming weeks and months through e-mails, newsletters and the BIDMC SPIRIT site on the portal. Also, I will be documenting our progress for the world to see on my personal blog, www.runningahospital.blogspot.com.

Finally, many thanks to Andrew French, Research Administrator, who came up with our program’s name, BIDMC SPIRIT: Solutions Promoting Improvement, Respect, Integrity and Teamwork.

Sincerely,

Paul

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And here is the Q&A that is referenced in the message above:

Frequently Asked Questions

The lights are too bright over my telemetry work station so it’s hard for me to read my screen, but if I turn off the switch it is too dark for the nurses at the rest of the nursing station. On…off…on… off. It doesn’t make sense. We need help!

When I mail a prescription to a patient and drop it in the BIDMC outgoing mail box it can take up to 10 days to get to the patient. We have resorted to buying our own stamps and dropping the envelopes in a US mailbox. Is this extra hassle really doing any good? We need help!

We are looking for a patient to bring down to angio. We have already searched in the day care unit and on the inpatient unit where we thought he was – but we found out that he went home yesterday! What a waste of time! We need help!

I needed an IV pump in my recovery bay and I searched all over for one before I found out that we had none! There has got to be a better way to do this! We need help!

What do these scenarios have in common?They are all “call-outs” – BIDMC staff declaring that something is keeping them from doing their jobs in the best way possible. The call-outs above are real situations that came up in the first wave of manager training sessions for BIDMC SPIRIT.

You probably remember the e-mail from Paul Levy around Thanksgiving in which he challenged each member of the BIDMC community to be part of a new way to consistently identify barriers to care and implement system-wide solutions as close to real time as possible.

As Paul said in his message: While the goal is simple, the solution is not. We want a solution that will identify and start to solve problems on the floors as they occur. We want a solution that will uncover and fix underlying problems, not result in yet another set of work-arounds.

The goal of SPIRIT is to make the work lives of all of our staff easier and more gratifying. To begin, we must all see and think about what we do every day in a new light. Chances are we all have work-arounds that we do every day without thinking. Or we waste time fetching and hunting for materials or resources we need and we may not even notice.

Once you identify a problem, the basic steps are:-- Call out a problem to your manager/shift leader.-- Work together to identify the root cause of the problem and solve it as soon as possible – in real time.-- Log it. (see below)-- Use the Help Chain, if necessary. (see below)

Less time hunting and fetching can mean more time spent on patient care – which will have a major impact on our goals of higher patient satisfaction and improved safety.

When and how will we start?We intend to launch the BIDMC SPIRIT program the first week of March.We have been busy orienting supervisors, managers, directors and vice presidents to the basic concepts of real time problem solving. We are working with a group of consultants from a company called Value Capture. They have experience in leading system wide change at the international manufacturer Alcoa and leading similar change initiatives at several academic hospitals.

How will it work?All employees will be asked to participate by “calling out” to their local manager/shift leader to report a problem related to hunting and fetching activities that are causing you to do work-arounds. Your manager/shift supervisor will help you to meet immediate patient needs as soon as possible. We call this “restoring the system.” Together, you will then log the problem into an electronic SPIRIT problem log (click on the SPIRIT logo on the general portal.) Your manager/shift leader will use real time problem solving strategies to facilitate a solution for the problem. Because you are the one who knows your work the best, you will be involved in the steps of finding a solution whenever possible. The goal for us is to have these call-outs addressed within 24 hours. The solutions will also be logged in the SPIRIT problem log.

I do most of my work in a patient care area, but I report to another department. To whom should I call out a problem?You have two choices:a) The unit’s nurse managerb) Your departmental supervisor

When you call out a problem, ask yourself who makes the most sense to provide help. (You don’t need to spend too much time deciding this – there’s no ‘wrong’ answer.) Here is some guidance:

Is the problem related to patient care or work done on the unit? Call the unit’s nurse manager.Example: While seeing a patient on Farr 7, a Case Manager finds that discharge paperwork isn’t ready at the right time. After solving the problem for the immediate patient, she calls out the problem to the Farr 7 nurse manager – because this problem involves the Farr 7 doctors, nurses and physical therapists and makes sense as part of the Farr 7 Unit Team.

Is the problem specific to your work, but not to the unit you’re working on? Call your usual supervisor.Example: While seeing a patient on Farr 7, a Case Manager notices a serious bug in the case management software. It doesn’t make sense to call the Farr 7 nurse manager as part of the help chain for this problem, so she calls her supervisor in case management.

What is the SPIRIT problem log?The SPIRIT problem log is a click away on the portal – just click on the SPIRIT logo on the top of the general portal. It provides a public space for you and your manager to log your “call-outs” and for us to track the various “call-outs” across the medical center. The SPIRIT log is not a notification system. Problems and work-arounds should be called out in person to your manager/shift supervisor whenever possible. At times when no one is available (night shift for example), go ahead and log it into the system anyway. Your manager will get back to you to involve you in problem solving if time allows. The SPIRIT log is visible from any public work station on the portal. The log will also track solutions. This will give us an opportunity to share the knowledge about fixes in one area that may be easily adapted for another area.

For patient safety reports or any report that requires the use of specific patient information, please continue to use the Patient Safety Reporting or Adverse Drug Alert or Adverse Event Management systems. The SPIRIT problem log does not provide the privacy protection needed when reporting patient related events.

What is the HELP CHAIN?Every department is specifying the components of its HELP CHAIN. The chain flows from the local manager to the director to the VP to the President’s office and then to the Board of Directors of the medical center. We are creating a comprehensive list of departmental manager HELP CHAIN contacts so that your manager will know the name of a manager in another department who can be called when the problem “call-out” and subsequent root cause and solution involve more than your home department. We imagine that this is going to be the case for many of the “call-outs.”

How will I know how it’s going?Information will be updated on the SPIRIT section of the portal. There will be weekly Friday e-mail updates about SPIRIT with a focus on stories about staff who are doing the work.

What about people who don’t use computers?For staff who don’t use computers, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, there is a special SPIRIT phone number, (66)7-7474, for staff to call in a fetching or hunting problem. Information from the weekly Friday e-mails will be collected and put into to a print newsletter.

What about staff for whom English is a second language?For staff whose primary language is not English, the preferred way to call out problems is still to talk to their managers/shift leaders. If a manager isn’t available, the special SPIRIT phone number, (66)7-7474, allows staff who speak Spanish, Portuguese or Haitian Creole to leave a detailed message in their first language. Staff from Interpreter Services will transcribe the messages and pass them on for the SPIRIT log. The print newsletter will also be translated into Spanish, Portuguese and French/Haitian Creole.

How can we possibly solve all of the problems called out? We know that this is not going to be perfect on day one! We are all going to learn this together. There will probably be many more problems called out than can be solved in real time. Having said this, the important thing is that we begin by trying to solve some – everyday. This is the main priority for our work this year. Solving more problems in real time and involving those closest to the work will result in smarter solutions and less formal problem solving meetings over time. Remember, to reach our potential for greatness, every employee should be able to answer the following questions with a resounding “YES!”

Am I treated with dignity and respect by everyone I encounter, regardless of role or rank in the organization?

Am I given the knowledge, tools and support that I need in order to make a contribution to my organization and that adds meaning to my life?

Did somebody notice I did it, i.e., am I recognized for my contribution?

good blog - just going thru the same situation myself and blogging how I need to take care of these types of problems in a more systematic way. Toyota apparently gets 24 suggestion per year per employee! Now that is the best example of "group think" www.waittimes.blogspot.com

the spirit initiative is alive and well with the patient site registration improvement work. We "fixed" the individual registration situation as i believe you know, then we initiated the set up of a meeting with the key folks, including a few of the the front line office staff who have a major role in the process, to resolve the system issue. The preliminary work by I.S., office staff, etc has been completed and i have reviewed the documents for our multidisciplinary meeting which is on the books for late this week where we will review the process flows for registration of patient site from all aspects: Patient role, Office staff role and physician's role/sign up. Once we review, we will look for components in the process for improvement and such, re-document the improved process and educate our staff and docs...will also send out general announcement on the pt site info for folks in terms of any changes. Thanks for asking....jayne

This thing seems simultaneously so massive as to be frightening and yet so hopeful precisely because it does involve the whole institution, from top to bottom. When the lab at my hospital suffered a massive IT implementation failure which led to process failures and then a state/CLIA inspection endangering the hospital's Medicare payments, I (the medical director) found it immensely frustrating trying to solve innumerable problems which might have come to light in the lab, but originated in the ER, nursing unit, test ordering process, etc. Since it was "the lab's problem", no one else cared about solving them. The State didn't care where they originated, just that I solved them.

A system-wide effort like this leaves nowhere to run and nowhere to hide. (: My only concern is, how to priortize the problems and how already-busy staff will take out the time from clinical work to do the root cause and go to all the cross-departmental meetings, as in the PatientSite example above. I hope there are extra people/overtime/whatever dedicated to this effort.Best of luck and I will continue following with great interest!

Dear Anonymous....just wanted to provide you an update on the Patient Site issues of timeliness in terms of registration you commented upon. We had our multidisciplinary meeting and confirmed the reasons for delays in the registration and turn around time from the offices. We have put in place an improved process of communicaiton from the Patient Site registration queue to the physician office staff that there is a registration request in their queue as well as notification to the person/patient who is requesting Patient Site access that registration could take several days for new patients to the system as we must confirm the patient and acquire approval by the physician to grant access. FOr instance, there are occasions when patients request to "sign up" for patient site, and chose a physician from the list, but have not yet seen the physician. It then takes time for the office to confirm that the patient is indeed new to the panel and the provider has approved their application....this is merely one example of the complexities around security and confirming of the patient to have permission to access the medical record PatientSite system.

However, i would like to again thank you for you facebook comment as it did allow us to review our processes, re-educate our office staff in turnaround time for established patients to be within 24-48 hours at optimal approval timeframe and it also allowed us to make recommendations which are in play, to improve our tutorial site for patients in terms of the registration process. THank you again for your interest in BIDMC and PatientSite. Regards, Jayne